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Redo Aorto-bifemoral Graft
45
History andPhysical Examination
A 65-year-old female was seen in the clinic for
symptoms of signicant bilateral lower extremity
claudication (50 yards) and ischemic rest pain in
the left foot in May of 2002, she had undergone
aorto-bifemoral graft reconstruction 15years earlier, and review of the old records revealed that
her symptoms were pain in the legs when walking 100 yards at that time. An aorto-bifemoral
graft reconstruction was performed with a Dacron
graft with proximal anastomosis being end to
side. She underwent Doppler arterial study of the
lower extremities which showed an ankle brachial index of 0.5 on the right and 0.38 on the left.
In addition, she underwent MRA of the abdominal aorta and lower extremities which showed
occlusion of the aorto-bifemoral graft with reconstitution of common femoral and profunda arteries with diffuse mild to moderate occlusive
disease of both supercial femoral and popliteal
arteries. She had diminished pulse in the left
upper extremity secondary to left subclavian
artery occlusive disease. Medical comorbidities
included hypertension and nicotine abuse (60
pack years). Past surgical history included left
carotid endarterectomy in 1999.
Procedure
On June 26, 2002, patient underwent redo aortobifemoral grafting. Proximal anastomosis was
carefully dissected with the help of sharp dissection, and incisions were made in each groin to
expose end the Dacron graft at the femoral anastomoses. A silastic vessel loop was passed around
the left renal vein. Proximal anastomosis of the
divided aorta was performed in an end-to-end
fashion with a 14 × 7mm knitted Dacron Gelsoft
graft using 4-0 cardiovascular polypropylene
(Ethicon) running suture. Previously placed
aorto-bifemoral graft (occluded) which was well
incorporated was removed. Distal end of the
aorta above the aortic bifurcation was sutured
with 3-0 cardiovascular polypropylene suture.
The left limb of the Dacron graft was brought
through the previously placed tunnel under the
ureter and anastomosed to the common femoral
and deep femoral artery as a long spatulated
anastomosis with 5-0 cardiovascular polypropylene suture. We had difculty on passing the graft
through the tunnel on the right side. We used an
8mm pilling dilator, and there was a tear in the
left common iliac vein which was controlled with
5-0 cardiovascular polypropylene suture. There
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_45
191
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45 Redo Aorto-bifemoral Graft
was sudden loss of about 400–500 cc of blood
from the tear of the left common iliac vein. Right
limb of the Dacron graft was brought under the
ureter and under the inguinal ligament anastomosed to the common femoral and deep femoral
artery with 5-0 cardiovascular polypropylene
suture and sutured in an end-to-side fashion. Her
postoperative course was uneventful; she was
discharged on the sixth postoperative day in satisfactory condition. She has been followed for the
past 17years, and her last ankle brachial index
(October 9, 2018) was 0.89 on the right and 0.77
on the left. She also underwent a follow-up CTA
of the abdomen and pelvis with runoff on
November 26, 2018, which showed 50% stenosis
at the origin of the celiac access, multifocal stenosis of the superior mesenteric artery, and patent
aorto-bifemoral bypass graft (Fig. 45.1). Both
femoral anastomoses were widely patent; there
was evidence of atherosclerotic plaque at the origin of the right supercial femoral artery as well
as mild to moderate stenosis throughout the
remainder of the mid and distal supercial femoral artery. In addition, the left supercial femoral
artery shows diffuse irregularly mixed atherosclerotic plaque with severe stenosis throughout
its course in the distal thigh. Patient underwent
left lower lobectomy in 2010 for carcinoma of
the lung. At last follow-up in June of 2019,
patient is doing very well, though she does complain of shortness of breath on exertion.
Discussion
Aorto-bifemoral grafting is one of the most effective and durable vascular reconstruction options
for patients with aortoiliac occlusive disease.
However, this procedure is associated with signicant perioperative mortality (3–5%). Aortobifemoral graft is also associated with signicant
perioperative morbidity (3.8–21.3%). The inci-
dence of surgical site infection and/or lymphatic
leak was reported in 3.5–22% of patients [1]. The
5-year patency of aorto-bifemoral graft ranges
from 87 to 91% and 10-year patency from 80 to
87% [1]. We have previously reported patency of
aorto-bifemoral graft at 48months to be 93% [2].
Scali etal. reported 19 patients who underwent
redo aorto- bifemoral graft operation for occlusive disease between 2002 and 2012 [3]. The
redo aorto- bifemoral bypass patients experience
greater blood loss, received more intraoperative
uids, and had longer overall procedure time [3].
They concluded that redo aorto-bifemoral bypass
procedures have higher procedural complexity
compared with the primary aorto-bifemoral
bypass [3]. However, they have similar perioperative morbidity/mortality and midterm survival.
This patient had a left common iliac vein injury
while making a tunnel for the passage of the right
limb of the graft. This resulted in sudden loss of
blood and patient needed two units of packed
cells. The aorto-bifemoral bypass has been patent
for the past 17years. Patient has developed bilateral supercial femoral artery occlusive disease
with minimal symptoms. Redo aorto-bifemoral
graft should be considered only in selective
patients who are otherwise good at risk for
occluded aorto-bifemoral graft. Other options
like axillofemoral bypass graft for patients with
occluded aortofemoral graft have poor patency. If
the patient has a hostile abdomen, a retroperitoneal aorto-unifemoral, and a crossover femoralfemoral using a retroperitoneal approach, or
alternatively a thoracic aorta to femoral bypass
may be considered [4]. Redo aortofemoral bypass
or thoracic aorta to femoral bypass should be
considered in good risk patients and axillofemoral bypass in poor risk patients following failure
of primary aortofemoral bypass. Patient’s comorbidities, experience of the surgeon, and life
expectancy of the patient should be taken into
account for the selection of the procedure.
Discussion
193
Fig. 45.1 Patent redo aorto-bifemoral graft with diffuse bilateral supercial femoral artery occlusive disease
194
45 Redo Aorto-bifemoral Graft
References
1. DeVries SO, Hunink MG.Results of aortic bifurcation
graft for aorto-iliac occlusive disease: a meta- analysis.
J Vasc Surg. 1997;26:558–69.
2. Hans SS, Desantis D, Siddiqui R, Khoury M.Results
of endovascular therapy and aorto-bifemoral grafting
for Transatlantic Inter-Society Type C and D aortoiliac occlusive disease. Surgery. 2008 Oct;144(4):583–
9.. discussion 589-90
3. Scali ST, Schmit BM, Freezor RJ, Beck AW,
et al. Outcomes after redo aorto-bifemoral bypass
for aorto-iliac occlusive disease. J Vasc Surg.
2014;60(2):346–55.
4. Passman MA, Farber MA, Criado E, Mariston
WA.Decreasing thoracic aorta to ilio-femoral bypass
grafting: a role for primary revascularization for
aorto- iliac occlusive disease. J Vasc Surg. 1999;29:
241–58.
Aorto-bifemoral Graft inaPatient
withHorseshoe Kidney
46
Physical Examination andHistory
A 61-year-old male was seen in the outpatient
clinic in February 2017 with severe hip and calf
claudication on walking a distance of 100 yards.
He did not complain of any ischemic rest pain or
night pain. Past medical history included hypertension and nicotine abuse (60 pack years).
Procedure
In June 2006 patient underwent a crossover
femoral- femoral bypass graft with 8 mm
INTERING® PTFE graft (W.L. Gore Inc.) by
another surgeon. A noninvasive arterial Doppler
study showed an ankle brachial index of 0.57
(left) and 1.0 (right). Toe brachial index on the
right side was 0.70 and on the left side was 0.33.
Aortography showed left common and external
iliac artery occlusion and occluded crossover
femoral-femoral graft (Fig. 46.1). CTA showed
horseshoe kidney (Fig. 46.2). Patient underwent
aorto-bifemoral graft reconstruction, proximal
anastomosis was performed end to side. A 16 ×
8mm knitted Dacron graft was used. The proximal vascular clamp was applied to the aortic neck
below the renal arteries and just above the isthmus of the horseshoe kidney. The inferior mesenteric artery was ligated, and divided graft was
brought in front to the isthmus and anastomosed
to the common femoral artery end to side after
the shelving edge of the inguinal ligament was
divided and retroperitoneal tunnels were made
under the ureters. His postoperative course was
uneventful; he was last seen in September 2017
with an ankle brachial index of 1.09 on the right
and 1.13 on the left, with a toe brachial index of
0.63 on the right and 0.64 on the left.
Discussion
Iliac artery occlusion (common and external iliac
ush occlusion) in this patient represented
TASC-D aortoiliac artery occlusive disease. Left
iliac stenting can be attempted provided there is
reconstitution of the common femoral artery
proximal to its junction with external iliac artery.
Primary patency of iliac stenting for TASC-D
aortoiliac artery occlusive disease is inferior to
aortofemoral bypass, but secondary patency is
similar. We are not certain from the old records
whether percutaneous intervention was attempted
in this patient. Primary patency of iliac stenting
for iliac artery occlusions is signicantly lower
than aorto-bifemoral graft reconstruction; however the secondary patency is equivalent [1]. In a
patient with horseshoe kidney, it is important to
determine the arterial supply to the horseshoe
kidney by catheter-based aortography and/or
CTA or MRA. If the arterial supply to the
horseshoe kidney is by one main renal artery
on each side then the open arterial bypass is a
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_46
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46 Aorto-bifemoral Graft inaPatient withHorseshoe Kidney
Fig. 46.1 Left common and external iliac artery occlusion
References
Fig. 46.2 CTA abdomen and pelvis shows horseshoe
kidney
straightforward operation. However, in a patient
as reported here with a large isthmus of the horseshoe kidney every attempt should be made to preserve the isthmus. If isthmus is reduced to a small
amount of brous tissue, then it can be safely
divided. Davidovic et al. reported 15 patients
who underwent abdominal aortic reconstruction
with horseshoe kidney (10 patients with aortic
aneurysms and 5 with aortoiliac occlusive disease) [2]. Angiography revealed multiple renal
arteries in 8 of 12 patients preoperatively. They
performed renal revascularization (7 patients
with reimplantation as a carrel patch and 3 with
aortorenal bypass) [2]. In this patient repeat
197
crossover femoral-femoral grafting could have
been attempted, but in view of patient’s age
(61 years) and a prior failed femoral-femoral
bypass grafting, it was felt that direct aortic
reconstruction (aorto-bifemoral graft) was preferred in a patient who has two main renal arteries and arterial supply to the horseshoe kidney
will not be sacriced by direct aortic
reconstruction.
In this patient iliac stenting could have been
considered before attempting open bypass grafting. Because of the long-standing occlusion of
the common iliac artery (ush occlusion) and
external iliac artery with satisfactory risk stratication, aortofemoral graft was preferred. In
patients undergoing arterial reconstruction for
TASC D lesions, iliac stenting is reported to have
inferior primary patency but equivalent secondary patency as compared to aortofemoral
grafting.
References
1. Hans SS, Desantis D, Siddiqui R, Khoury M.Results
of endovascular therapy and aorto bifemoral grafting
for Transatlantic Inter-Society Type C and D aortoiliac occlusive disease. Surgery. 2008;144(4):583–9;
discussion 589–90
2. Davidovic LB, Kostic DM, Jakovljevic NS, Perisic M,
etal. Abdominal aortic surgery and horseshoe kidney.
Ann Vasc Surg. 2004;18(6):725–8.
Spiral Vein Graft forRadiationInduced Right Common
andExternal Iliac Artery Occlusion
47
History andPhysical Examination
A 34-year-old male was seen in our outpatient
clinic in October of 1998 with signicant pain
and discomfort in the right lower extremity on
walking 50 yards. He also complained of ischemic rest pain and night pain. His right femoral
popliteal posterior tibial and dorsalis pedis pulses
were absent, and on the left side, the pulses were
present all the way from the groin to the foot. At
age 17 (May 1982), patient had undergone left
orchiectomy for a peri-testicular rhabdomyosarcoma involving the spermatic chord. At that time,
he was found to have enlarged preaortic and paraaortic lymph nodes and underwent retroperitoneal lymph node dissection. In the postoperative
period, he received chemotherapy and radiation
therapy. The lymph nodes were also positive for
undifferentiated mesenchymal sarcoma (rhabdomyosarcoma). Medical comorbidities included
hypertension, type I diabetes mellitus, and nicotine abuse (20 pack years). Retrograde abdominal
aortography and study of the lower extremities
(runoff) via left femoral approach revealed right
common and right external iliac artery occlusion
with very poor collaterals and reconstitution of
the right common femoral artery with good runoff (Fig.47.1).
Procedure
Because of the radiation therapy to the retroperitoneal tissues, it was felt that a standard synthetic
bypass graft would not be an ideal conduit in this
situation as there will be difculty obtaining tissue coverage of the graft; therefore it was decided
to perform a spiral vein graft. Right greater
saphenous vein was harvested from the groin to
the ankle. A 16cm long and 8 mm in diameter
spiral vein graft (reconstructed from greater
saphenous vein) from the right lower extremity
over a 24-F chest tube was performed from the
aortic bifurcation on the right side to the common
femoral artery. Proximal control was obtained at
the level of distal abdominal aorta. Left common
iliac artery was clamped as well prior to proximal
anastomosis (aorta/right common iliac artery
junction). In the postoperative period, patient
developed tachycardia, the cause of which was
not apparent. Patient had palpable dorsalis pedis
and posterior tibial pulse with an ankle brachial
index of 0.9 on the right and 1.0 on the left.
Patient was admitted 1 month later to the hospital
with deep venous thrombosis involving the right
femoral vein and was probably secondary to
dehydration as patient developed abdominal
pain, nausea, and vomiting and had not taken oral
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_47
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200
47 Spiral Vein Graft forRadiation-Induced Right Common andExternal Iliac Artery Occlusion
Fig. 47.1 Aortography showing right common and exter-
nal iliac artery occlusion
uids for many days. Patient underwent follow up abdominal aortography which showed patent
graft from the origin of the right common iliac
artery to the femoral artery (Fig. 47.2).
Laparotomy revealed extensive scarring in the
retroperitoneum and virtually non existent greater
omentum which precluded the use of synthetic
graft due to inadequate graft coverage. Thus, spiral vein graft was preferred as an arterial conduit.
Patient was last seen in September 2003in satisfactory condition with palpable pulses, and he
was advised to come for follow-up but has not
returned.
Discussion
Favorable long-term results of spiral vein grafts
as substitutes for superior vena cava have been
reported, yet there are relatively few reports
regarding the use of spiral vein grafts in aortoiliac and femoral artery reconstructions [1].
Various alternative approaches in management
of arterial occlusion in this patient include
Fig. 47.2 Postoperative arteriography showing patent
graft
crossover femoral-femoral bypass graft or use
of deep veins as arterial substitutes. Clagett
etal. have reported the use of deep venous system (femoral and popliteal veins) after removal
of infected aortoiliac and femoral grafts with
10% in-hospital mortality 10% incidence of
amputations [2]. The advantages of using deep
veins as a neo-aortic system are resistant against
infection and excellent patency at intermediate
term follow-up. But the deep veins require
extensive dissection for harvesting and because
of their thin walls are difcult to handle and
undergo graft dilatation [2]. In addition, harvesting of the deep venous system in association with removal of the saphenous vein can
cause signicant venous edema. The disadvantages of spiral vein graft include long suture
line necessary for construction of saphenous
vein as a potential for neointimal hyperplasia
resulting in stenosis of the graft [1]. In addition,
there is propensity for vein graft dilatation as it
is subjected to higher pressure as an aortoiliac
conduit [1].
References
201
Radiation-induced arteritis is a rare but wellrecognized complication of radiation therapy.
Those lesions are often indistinguishable from
atherosclerosis; however the arterial involvement
is mostly conned to the irradiation eld [3].
Histological changes include brosis of internal
elastic membrane, injury to vasa vasorum, ischemic necrosis of the vessel wall, periarterial
brosis, hyalinization, and thickening of the vessel wall with deposition of brosis [3]. The dose
of radiation associated with such lesion is
39.0 –80Gy [3]. Angioplasty and stenting have
been performed with good short-term results.
These lesions require high ination pressures [3].
The patient described here has a TASC-D lesion,
and open surgical bypass is generally preferred
for a long segment occlusion. Patient’s younger
age and extent of the lesion led us to favor open
surgical reconstruction in this patient.
References
1. Hans SS. Spiral vein grafts as vascular conduit in
irradiated and contaminated tissue beds: a report of
ve cases a midterm follow up. J Am Coll Surg. 2002
Nov;195(5):732–6.
2. Claggett GP, Bowers BL, Lopez-Vigo MA, Rossi
MB.Creation of a neo aorto-iliac system from lower
extremity deep and supercial veins. Ann Surg.
1993;218:239–48.
3. Baerlocher MO, Rubin BB.Primary stenting of bilateral radiation induced external iliac stenosis. J Vasc
Surg. 2004;40(5):1028–31.